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Veterinary critical care

Department of Veterinary Clinical Sciences, Royal Veterinary College, University of London, Hawkshead Lane, North Mymms, Hatfield, Herts, AL9 7TA, UK b Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Ontario N1G 2W1, Canada c Department of Clinical Studies Philadelphia School of Veterinary Medicine, University of Pennsylvania, 3850 Spruce Street, Philadelphia, PA 19104, USA d Hagyard-Davidson-McGee Associates, PSC 4250 Iron Works Pike, Lexington, KY 40511-8412, USA

Emergency medicine and critical care is one of the most dynamic and rapidly developing specialties in veterinary medicine today. It is still a relatively new area compared to other specialties in veterinary medicine, although the initial interest in this area dates back to the 1950s. Veterinary critical care was pioneered by a small group of individuals, but its acceptance into mainstream veterinary medicine really began when a critical mass of individuals formed societies to promote its development. The Veterinary Critical Care Society was established in 1978, and 5 years later the Veterinary Anesthesia Society joined the Veterinary Critical Care Society. In 1984, the Veterinary Emergency and Critical Care Society was formed from the merging of the Veterinary Critical Care Society and the American Association of Veterinary Emergency Clinicians. The Journal of Veterinary Emergency and Critical Care has been published by Veterinary Emergency and Critical Care Society since 1991. In 1988, the Veterinary Emergency and Critical Care Society held the first International Veterinary Emergency and Critical Care Symposium in San Antonio, TX. This symposium has grown into a major annual event attracting approximately 2000 delegates. In 1989, the American College of Veterinary Emergency and Critical Care was founded and is now the body that certifies veterinarians as emergency and critical care specialists. To be eligible for

* Corresponding author. E-mail address: kcorley@rvc.ac.uk (K.T.T. Corley). 0749-0704/03/$ see front matter D 2003, Elsevier Science (USA). All rights reserved. PII: S 0 7 4 9 - 0 7 0 4 ( 0 2 ) 0 0 0 4 7 - 7

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examination for board certification candidates must complete 4 or 5 years of veterinary school followed by a 1-year internship then a 3-year residency program. There are currently 90 veterinary emergency and critical specialists who hold board certification by the American College of Veterinary Emergency and Critical Care (ACVECC). Many U.S. colleges of veterinary medicine and a small number of Canadian and European schools now have academic posts in small animal emergency and critical care, the majority of which are held by ACVECC diplomates. Many areas in the United States also have boarded emergency and critical care specialists working in private practice. Interest in veterinary emergency and critical care is spreading throughout the world, as evidenced by interest societies on most continents. For example, the European Veterinary Emergency and Critical Care Society was founded in 2002. In addition, there is an Academy of Veterinary Emergency and Critical Care Technicians offering certification in emergency and critical care nursing and a Student Veterinary Emergency and Critical Care Society. The majority of emergency and critical care specialists work with dogs and cats (small animals) but there are an increasing number who work with large animals, currently almost exclusively horses. Equine critical care began as a collaboration in the early 1980s between coworkers from Newmarket, England, and the University of Florida based on their long-standing interests in neonatal

Fig. 1. German Shepherd following surgery for gastric dilatation volvulus with continuous ECG, central venous pressure, and direct arterial pressure monitoring.

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foal medicine. They applied principles of human neonatal care to foals, with help from human neonatologists (notably Willa H. Drummond, MD). Their encouraging results, and those of others in specialist private practice who were developing neonatal care along similar lines, led to more widespread development of neonatal equine critical care units. During the 1990s, the principles of critical care began to be applied to adult horses as more equine specialists became interested in the discipline. Two equine neonatologists were incorporated as ACVECC charter diplomates and the first equine veterinarians became boardcertified by the ACVECC by residency and examination in 1996. In 2001, equine critical care took a further step forward when academic posts specifically in critical care were created at the University of Pennsylvania, the Royal Veterinary College, UK and, in 2002, at Texas A&M University. Veterinary critical care progressed as veterinarians realized that applying a standard of care approaching that of human medicine can result in survival of animals with conditions previously thought to be fatal. Even animals with severe medical or surgical conditions can be treated successfully [1 3] (See Fig. 1). Dogs, cats, and horses are the main species that receive critical care; however, in certain circumstances zoo animals, exotic pets, and farm animals also benefit. Due to many similarities in critical care conditions of veterinary species and humans, veterinary intensivists frequently refer to the human and animal research literature when managing these patients. Also, as occurs in human medicine, the owners (relatives) of these patients force the continual search for a cure by bringing the literature they have obtained from the World Wide Web. Society demands that veterinarians do everything, and this is what veterinary intensivists strive to do.

Critical care for cats and dogs Cats and dogs are an integral part of our society. The evidence for the human animal bond and increased health in families with pets supports the importance of animals in the family [4 7]. Several years ago it was reported that 40% of American households had a dog, and many nondog households had a cat [4]. Working dogs such as the search and rescue teams [8], police tracker and narcotic searchers, airport food and explosive material searchers, farm and ranch dogs, seeing-eye and hearing dogs, and the dogs for special needs patients, to name a few, perform tasks that people cannot do or that would be difficult for any one person to do. The special need dogs are trained to assist para- and quadriplegic patients with many daily tasks, such as helping the patient in and out of bed, turning the patient, opening refrigerator doors and retrieving specific items. These dogs are usually worth U.S. $25,000. The costs for training and medical care of dogs of all handicapped owners are funded by organizations such as the Lions Club, at no cost to the owner. It is the recognition and appreciation of the importance of these animals in our society and our lives that puts them in a similar category as the human members of the work force and the family when considering medical care.

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For many individuals the crisis resulting from pet loss has been found to be extremely intense. The bereavement process of pet owners has been found to closely approximate the grief process experienced as a result of human deaths and this grief is as intense and emotionally and cognitively debilitating as is found when a family member dies [9]. Frequently, working dogs are either insured for medical coverage or the employer (police force, federal government agencies) is responsible for medical care. Unfortunately, the family pet has to rely on the owners ability to pay for veterinary care if the pet is not insured. Poor prognosis for recovery and inability to pay for medical care are the main reasons for euthanasia. The financial constraints make the death more difficult to bear. Although pet insurance is relatively uncommon in the United States, it is widespread in the United Kingdom. In some referral hospitals 70 80% of pets are insured, often up to 4,000 (approx $5900) per illness. This is often adequate to cover the intensive care costs incurred. This means that critical care can be provided without a serious financial burden to the owner. The illnesses that result in admission to a veterinary intensive care unit are varied; these include emergent or critical neurologic, medical, respiratory, septic, surgical, traumatic, toxicologic, neonatal, obstetrical, oncologic, and ophthalmologic conditions [1 3,10,11]. It is difficult to give the breakdown of the various conditions, as patient population will vary among the institutions. Regardless of the primary problem resulting in admission to the intensive care unit (ICU), multiple organ dysfunction or failure is either present in the seriously compromised patient upon admission or is a potential concern in those that are not appropriately managed. Therefore, while treating the primary problem, management and prevention of multiple organ dysfunctions or failure is an important aspect of critical care. Acute lung injury and Acute Respiratory Distress Syndrome (ARDS) occur in animals and the consensus definitions of these conditions in humans has been applied to veterinary patients. Respiratory failure requiring mechanical ventilation has many causes and risk factors [2]. The inflammation that results in acute lung injury and ARDS may originate in the lung due to a direct pulmonary insult, or may be part of a generalized inflammatory response. In many of the veterinary clinical reports, ARDS occurred as a sequel to sepsis or systemic inflammatory response syndrome (SIRS) (Fig. 2) [12 14]. Organ torsion triggered SIRS and ARDS in dogs as a result of tissue necrosis and ischemia reperfusion injury [13,15,16]. Sepsis due to canine parvoviral enteritis resulted in ARDS in 69% of dogs in one study of necropsy findings [14]. Necrotizing pancreatitis was also reported to cause SIRS and acute lung injury in one canine case report [17]. Also, ARDS may be triggered by local pulmonary catastrophes such as severe aspiration or bacterial pneumonia, pulmonary contusions, or smoke inhalation, which all may trigger an inflammatory response that can become generalized within the lung parenchyma [13,15]. Noninflammatory conditions requiring mechanical ventilation include noncardiogenic pulmonary edema such as flash pulmonary edema of many causes, near drowning, high cervical lesions [18], and thoracic trauma [19].

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Fig. 2. Rottweiler with systemic inflammatory response syndrome and cranial vena caval thrombosis.

Conditions that affect the cardiovascular system in cats and dogs are similar to those that occur in humans. Hypovolemic, cardiogenic, distributive, and septic shock all require intensive supportive care [1]. Cardiovascular monitoring includes central venous pressure, direct and indirect arterial blood pressure, measurements of cardiac output, wedge pressure, and oxygen delivery [1]. Resuscitation with crystalloids, colloids, and blood products and the use of pressors and inotropes is similar in dogs and cats to human patients [1,20]. Primary cardiac diseases, resulting in congestive heart failure or cardiovascular collapse, occur in both cats and dogs. Many of the antiarrhythmic, vasodilator, and vasoactive agents used in human patients to treat the primary and secondary problems of heart disease are also used in veterinary cardiac patients [1]. Temporary pacemakers are placed in emergent situations, and the patient is managed in the ICU until stabilized for permanent placement of a pacemaker. Survival following cardiac arrest is lower in dogs and cats than in people because there is a low prevalence of coronary artery disease in small animals, and most cardiac arrests are due to severe underlying disease. Respiratory and nonrespiratory acid-base and electrolyte disorders are common in the ICU patient. Hyper-, hyponatremia; hypo-, hyperchloremia; hypo-, hyperkalemia; hyper- hypomagnesemia; and hyper-, hypocalcemia occur primarily or secondary to many illnesses. Nonrespiratory acidemia is frequently due to lactic acidosis, diabetic ketoacidosis, uremic acidosis, ethylene glycol intoxication, or tumor lysis syndrome, to name a few. Less frequent causes of acidemia are hyperproteinemia and hyperphosphatemia. Nonrespiratory alkalosis occurs less frequently than acidemia, and in veterinary patients is most commonly due to

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gastric vomiting or frequent suctioning, loop diuretics, fluid therapy with alkalinizing solutions, sodium bicarbonate, and potassium nitrate administration. High-dose corticosteroids, hyperadrenocorticism, hypoproteinemia, and primary hyperaldosteronism are less frequent causes of alkalemia [1]. Frequent monitoring of the acid-base status and appropriate adjustment of intravenous fluids such as selection of an alkalinizing or acidifying crystalloid solution or a colloid is an important aspect of managing the critical patient [20]. Acute renal failure of various causes, many similar to those of the human patient, is a frequent reason for admission to the ICU. These patients are managed with intravenous fluids with or without the addition of mannitol or furosemide; dopamine is occasionally administered. In patients that are unresponsive to this therapy, peritoneal or hemodialysis maybe available depending on the institution and geographic location [21]. Some animals are transported very long distances for hemodialysis. Should renal damage be irreversible, renal transplantation is a potential alternative to euthanasia [22]. Due to the curiosity and dietary indiscretion of dogs, toxicologic emergencies are not uncommon in veterinary medicine [10]. Frequently, these patients require intensive care to support the vital organs during elimination and antagonism of the toxic agent. The most common poisons seen include anticoagulant rodenticides, flea products, human prescription, and over-the-counter medication (such as nonsteroidal antiinflammatory drugs), automobile antifreeze (ethylene glycol), and chocolate. Dogs cannot metabolize or excrete methylxanthines as rapidly as humans, making them especially sensitive to chocolate and caffeine toxicity. Hematologic problems such as anemia (immune-mediated lysis, toxic, neoplastic, clotting factor deficiencies, decreased red blood cell production), thrombocytopenia, disseminated intravascular coagulation to name a few [11], are common to veterinary patients requiring critical care for several days to weeks. Blood transfusions, blood component therapy, and use of artificial hemoglobin solutions (Oxyglobin, Biopure Corporation, Cambridge, MA) are relatively common in veterinary emergency and critical care. Pain management is critical in all our patients. Sometimes pain assessment is difficult, and the clinician has to be very observant with respect to behavioral changes associated with pain. Anthropomorphism is also an important tool in the assessment of pain. As the mechanism of transduction, transmission, spinal modulation, and perception of pain is similar in all animal species, the many pharmacologic agents and modalities used to manage pain in humans are also used in animals [23].

Equine critical care The decision to institute intensive care in horses: costs, economics, and ethics Intensive care costs for horses are relatively inexpensive compared to the costs of human medical care. However, potential costs can be a significant factor in

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decision making prior to embarking on intensive care or electing for euthanasia of the animal. Horse owners can be broadly characterized as commercial or noncommercial operations. In commercial operations medical decisions for the horse are based on economic judgements. The decision whether to pursue intensive care for noncommercial owners is based on the financial resources of the owner and the perceived value (emotional or monetary) of the horse. Many horse operations cannot be neatly fitted into these categories, and may be classed as semicommercial. The cost of foal intensive care is relatively small compared to potential profits for high-end Thoroughbreds destined for race training. For example, the median sale price for yearlings at the Fasig-Tipton Saratoga Select Yearling Sale in August 2000 (in U.S. dollars) was $190,000 [24]. However, many yearlings will sell for less than this price, and the cost of getting a foal from birth to the sales can be in the region of $20,000 to $25,000 [25], excluding the stud fee for the stallion. The financial situation is complicated by tax rules, and the change in financial worth of breeding stock based on the success of their offspring. It can be difficult to determine in pure economic terms whether intensive care is worthwhile for foals expected to sell for less than $25,000 as yearlings. For adult horses, the economics are even more complicated, and depend on the length of likely convalescence against the projected career length as well as the financial worth of the horse. Many adult horses in the United Kingdom are insured for veterinary fees up to 5,000 ($7300). The uptake of insurance is less in the United States, and veterinary fees are often capped at $5000. In both countries, claims usually result in exclusion of the affected body system from any future insurance. The costs and outcome for critical care must be reviewed in the light of this economic background. Costs, hospital stay, and outcome statistics for 1999 at a major referral center in the Mid-Atlantic Region of the United States for neonatal foals were as follows: 51 foals less than 7 days old were admitted to the ICU. Thirty-seven (72.5%) survived to hospital discharge. The median hospital length of stay (LOS) of survivors was 7 days (range 2 38 days). The median LOS of nonsurvivors was 15 hours (range 1.5 hours to 19 days). Twelve of the 15 nonsurvivors were euthanized, 8 of these within 24 hours of admission. Two of the three foals that died did so within the first 24 hours. The LOS for a particular patient is not purely a clinical decision, but also based on owner economics and the availability of referring veterinarians for aftercare. Some of these foals were discharged to the referring veterinarians hospital facilities or to stud farms with resident veterinarians. Data for cost, length of treatment, or outcome after hospital discharge are not available. The median and mean total hospital cost (in U.S. dollars) for hospitalization for survivors were $3140 and $4500, respectively. The highest bill for a survivor was $15688. The median and mean bills for nonsurvivors were $1770 and $2410, respectively. The mean cost per life saved was $5358 (calculated as the total sum cost for treatment for all 51 foals, divided by the number that survived). For comparison, hospital bills at a large private referral practice in Kentucky

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average between $5000 and $7000. Costs and length of stay were greater for foals with confirmed sepsis. The median LOS for surviving septic foals (16 of 27 septic foals) was 10.5 days, and the median cost was $5360. Seven of these foals had severe septic shock, unresponsive to dobutamine and/or dopamine. All seven were treated with norepinephrine, three survived. The LOS for these survivors ranged from 22 to 38 days [12], and the total bill ranged from $12,275 to $15,688. The mean cost per life saved for foals with severe sepsis was $20,194. All three severe sepsis survivors were race horses, and are currently in race training in the United States and France. The cost for adult horse intensive care varies markedly between conditions. Taking surgical conditions of the gastrointestinal tract as an example (one of the most common reasons for intensive care; see below), the outcome, LOS and costs for a major referral center in the south-east United Kingdom in 2000 2001 were as follows: 60% of horses survived to hospital discharge. The majority of nonsurvivors were euthanized during surgery because of the severity of the lesion. The survival rate for intensive care following abdominal surgery was 89%. The mean LOS of survivors was 9 days (range 3 to 19 days). The mean total cost of hospitalization for survivors was 2,700 ($4000), but some bills exceeded 5,000 ($7300). For many horses undergoing critical care, the only outcome considered successful is full athletic ability. For some horses (eg, some racing Thoroughbreds and Standardbreds), impaired athletic ability with reproductive function intact is an acceptable outcome. Unproven females with proven close family are likely to be retained for breeding. It is rare to breed unproven males. For a few horses, particularly those kept by individuals in noncommercial operations, an acceptable outcome can be the ability to walk round a pasture pain free. For these reasons, owners are less likely to request treatment for major orthopedic injury than for abdominal lesions.

Adult versus neonatal equine critical care Equine critical care is usually divided into care of the neonatal foal and care of older horses. In larger hospitals, this division is also physical, with dedicated areas for the care of neonates. However, because of the seasonal nature of equine foaling (peak from January to May in the Northern Hemisphere, August to December in the Southern Hemisphere), there are very few veterinarians and nurses who exclusively practice equine neonatology. For many reasons, foals within the first 7 days of life represent the best equine candidates for critical care. In many respects, this is a weight issue. Newborn foals range in weight from approximately 10 kg (miniature horses) to 90 kg (draft breeds). Adult horses typically weigh approximately 10 times the weight of a newborn foal. The logistics involved with managing recumbent animals weighing 500 kg and the large costs of drugs for this body weight can frequently limit the scope of critical care in adult horses. Conversely, recumbent newborn foals are much easier to manage, drug costs are less, and much

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of the equipment designed for humans can easily be adapted to animals in this weight range. Critically ill neonatal foals are also generally more likely to recover to become athletes than their adult counterparts.

Conditions seen As in human medicine, the definition of critical illness in horses varies between hospitals. The easiest definition for neonatal foals is any foal under the age of 7 days, requiring fluid therapy. This is clearly a broad definition, but takes into account the rapid onset of severe compromise seen in neonates. Using the definition, 191 critically ill neonates were seen at a major referral center in the Mid-Atlantic region of the United States between January 1998 and July 2001. The major conditions seen were bacteremia (33.5%), local bacterial infection (umbilical infection, pneumonia, septic arthritis, and pyelonephritis; 35.6%), hypoxic ischemic encephalopathy (18.8%), colitis (11.5%), prematurity (6.8%), meconium impaction (4.2%), strangulating intestinal lesion (4.2%), and patent urachus (3.1%). Other conditions (each seen in less than 3% of foals) included abdominal pain of uncertain etiology, neonatal isoerythrolysis, fractured ribs, cranial trauma, and cystorrhexis. Many foals had more than one diagnosis. Many critically ill foals have some degree of renal insufficiency, and 36% of foals presented with a plasma creatinine concentration greater than 3.4 mg/dL (300 mmol/L). However, in foals less than 12 hours old, this may be more reflective of placental insufficiency rather than hypovolemia or nephropathy. Case-mix and caseload can vary markedly between hospitals. Four hundred fifty foals, on average, are treated annually at a large private referral practice in Kentucky. In that hospital, hypoxic ischemic encephalopathy represents 80 85% of the caseload, and sepsis is seen in 30 40% of foals, either as a primary condition or confounding factor. The definitions of intensive care are even less well determined for adult horses. Hospitals may or may not have a dedicated area for intensive care, and admission criteria vary greatly between institutions. Based on a very broad definition of horses that during part of their hospitalization had a physical examination more frequently than every 6 hours, 408 horses were attended by one of the authors (K.C.) over a 2-year period (1999 2001) in the Mid-Atlantic area of the United States. The vast majority (71.1%) of these horses had a condition related to gastrointestinal tract. Two hundred sixty horses (63.7%) had been referred for acute abdominal pain (colic), resulting in an exploratory celiotomy in 121 patients. Of the horses that went to surgery, 61% had a lesion distal to the ileum and 46% had a lesion involving strangulation of the intestinal blood supply; 9.7% of horses with gastrointestinal disease had severe colitis (in most cases due to Clostridia spp., Salmonella spp., or Ehrlichia risticii). Other body systems requiring major interventions in these 408 horses were the respiratory system (9.8%), the musculoskeletal system (8.1%), the neurologic system (5.4%), the urinary system (5.1%, including acute renal failure in 2% of

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horses), the reproductive system (4.4%), and the cardiovascular system (2.9%, 66% of which involved cardiac dysrhythmias). The hematopoietic system, the liver, and biliary tree, and localized or disseminated neoplasia each accounted for less than 2% of horses seen. Twelve percent of horses had major lesions of more than one system. There are great case-mix differences between hospitals, partly because of geographic nature of some conditions and partly due to reputation or expertise of individuals at each institution. However, gastrointestinal conditions predominate at almost all hospitals.

Critical care of neonatal foals Typically, recumbent neonatal foals are managed on soft mats and turned every 1 to 2 hours to prevent decubitus ulcer formation (Fig. 3). Depending on the degree of consciousness of the foal, a handler (frequently a volunteer or student) may be employed to keep the foal in sternal recumbency (prone position). Continuous sedation is rarely used, except in foals with seizure disorders such as hypoxic ischemic encephalopathy. The external jugular vein is most frequently used for delivery of fluids, drugs, and parenteral nutrition and

Fig. 3. Two-day-old Thoroughbred foal with septic shock. The foal is being treated with continuous infusions of crystalloid fluids, parenteral nutrition, dobutamine, norepinephrine, insulin, and furosemide, and with mechanical ventilation.

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double- or triple-lumen catheters are often used for this purpose. Many foals receive intranasal oxygen as respiratory support, and approximately 5 10% are mechanically ventilated, using a nasotracheal tube for airway access. Highfrequency jet ventilation [26] and inhaled nitric oxide [27] have been used on an as-yet limited number of foals, and the advantage of either over conventional mechanical ventilation is still unclear at this time. Hemodynamic disturbances are relatively common in recumbent foals. Although pulmonary artery catheters have been used experimentally in foals, there are no clinical reports of their use. However, more recent and less invasive technology, such as lithium dilution cardiac output monitoring, has been used to guide therapy [28]. Arterial blood pressure is relatively easy to measure in the greater metatarsal artery, but maintenance of catheters can be a problem in seizuring foals and foals that are not comatose or sedated. Noninvasive blood pressure, urine output monitoring, central venous pressure, and blood lactate concentrations are used routinely. The normal cardiac output of a neonatal foal is in the order of 9 L/min. Normal arterial blood pressures for foals are similar to equine adults (mean pressure approximately 80 100 mmHg), perhaps reflecting a relatively mature cardiovascular system at birth (allowing the foal to get to its feet an hour after birth and run a short while later). The systemic vascular resistance is therefore lower than humans at approximately 700 dynesscm 5 for the first 3 days of life. The systemic vascular resistance decreases during the first month of life [29]. Therapeutic strategies and treatments used for hemodynamic disturbances are similar to human medicine [12,30]. In foals with hemorrhagic shock or neonatal isoerythrolysis, polymerized (bovine) hemoglobin has proven to be a useful bridge until suitable donor blood can be identified and prepared [31]. Hemodialysis has been used in a foal with acute renal failure secondary to oxytetracycline administration [32]; however, this is the exception rather than the rule, as equipment for hemodialysis is not widely available in equine hospitals. Clinical experience suggests that the vast majority of acute renal failure seen in neonatal foals is due to hemodynamic causes, and when therapy aimed at the cardiovascular system is successful, the nephropathy often begins to resolve. Gastric ulceration is a particular issue in neonatal foals. There is some debate as to whether acid suppressors are effective in this patient group, as limited data suggests a proportion of critically ill foals already have high intragastric pH and that ranitidine has little effect in these patients [33]. There is also some evidence, based on historic controls, that administration of acid suppressors has no effect on the prevalence of ulcers at postmortem examination [34]. Intermittent hyperbaric oxygen therapy (delivered by specially designed equine chambers) is being used in clinical trials for foals with septic joints, hypoxic ischemic encephalopathy, and septicemia. The case-mix figures above show that, unlike human neonatology, equine neonatology is not dominated by premature patients. Because birth weight is very variable between breeds and even individuals in a breed, foals do not tend to get classified by birth weight. The normal gestation for a horse is in the order of 335 345 days (it tends to vary between breeds and individuals). Most foals born

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prior to 320 days will show some evidence of prematurity, and the prognosis is guarded for foals of less than 305 days and fairly hopeless for foals of less than 280 days. Foals born prematurely from an obviously infected uterus tend to be more mature and have a much better prognosis than those born prematurely without any evidence of infection. Foals may also be born at term, with signs of prematurity (dysmaturity or intrauterine growth retardation). Although lack of endogenous surfactant production is a major issue in premature foals, another very important parameter in premature foals is the degree of ossification of the small cuboidal bones of the carpus and tarsus. Incomplete ossification of these bones is a major limiting factor in future athletic ability, and leads to the early euthanasia of many of these foals. There are, however, anecdotal reports of survival to athletic ability with absent ossification. Several severity scores have been developed for neonatal foals [35 37], but none have been validated in more than two centers, and they are not currently widely used. A score for predicting sepsis at hospital admission [38] has been more widely used, but recent evidence suggests the sensitivity and specificity of the test may be significantly less than originally published [39].

Critical care of weanlings and older horses The greater the weight of the horse, the harder it becomes to provide some aspects of intensive care. The greatest problem is recumbency. A typical adult Thoroughbred weighs 450 kg. Even relatively healthy horses are prone to recumbency rhabdomyolysis and ventilation perfusion mismatching during short-term (2 4-hour) anesthesia. For this reason, recumbent animals are rarely successfully managed. Water or air beds, and mechanical hoists (or a large amount of manpower) for turning horses are required. Swimming pools (with a waterproof raft for the patient) are used at some institutions to recover horses following orthopedic surgery, and it is possible that they could be adapted for recumbent horses. The best success with recumbent horses has been with horses with a reversible condition, such as botulism, and where the horse is a yearling (250 350 kg), rather than a full-grown adult. Even at 6 mL/kg, ventilators made for the human market (highest tidal volume approximately 2 L), are not suitable for many adult horses. Ventilators manufactured for equine anesthesia can be used, but are typically simple in their design and are not suitable for long-term ventilation. Again, ventilators have been most successfully employed in cases of botulism. Other equipment made for the human market, such as defibrillators are also not suitable for adult horses, and no equine equivalents are made (they might fuse the entire hospital!). The cardiovascular system of adult horses is high throughput (cardiac output typically 35 40 L/min) and low resistance (systemic vascular resistance 200 250 dynesscm 5). Initial data suggests that during and for 12 hours following surgical correction of intestinal strangulation, stroke volume is reduced to 50 60% of normal (approximately 1 L). This would support current clinical practice, which

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is to administer large volumes of intravenous fluids and support with dobutamine, if required. The large blood volume of adult horses (approximately 40 L) means that great volumes of crystalloids are required for fluid resuscitation, and has led to the popularity of hypertonic saline and hydroxyethyl starches for this purpose. The combination of hypertonic saline and dextrans leads to clinically significant intravascular hemolysis in the horse [40]. The SIRS is common in adult horses undergoing intensive care, particularly in those following surgical correction of intestinal strangulation. It is also prevalent in horses with enteritis, colitis, pleuropneumonia, and metritis. The response is usually attributed to endotoxemia, as endotoxin can be detected in the plasma of approximately 25-30% of horses referred for acute abdominal pain [41]. However, the physiologic responses of horses to experimental endotoxin administration do not exactly match the clinical picture. Horses with SIRS are prone to clotting abnormalities and laminitis. Laminitis describes pathology of the dermal laminae that attach the hoof capsule to the pedal bone (third distal phalangeal bone), and can result in total detachment of the hoof capsule. The etiopathogenesis is still hotly debated, and current therapies are limited in their ability to prevent or reverse the condition. Laminitis is one of the major causes for euthanasia of adult horses undergoing intensive care. The stomach of the horse is relatively small (8 15 L). Horses are hind-gut fermentors. Breakdown of cellulose takes place in the large cecum (equivalent to the appendix, but with a volume of 28 36 L) and the large intestine. This has limited enteral nutrition in horses with insufficient voluntary intake, as formulas high in carbohydrate result in changes to the microbial flora of the hind gut, severe colitis, and frequently laminitis. For this reason, parenteral nutrition is used more commonly than gastric tube feeding. It has proven to be difficult to formulate a fiber-based diet that is sufficiently energy dense, passes easily through the feeding tube, and is appropriate for equine digestion.

Summary Veterinary species experience similar perturbations of their health to those of human patients. When the long-term prognosis is good and providing suffering can be minimized, animals stand to benefit greatly from recent advances in the field of emergency and critical care. Outcomes in many conditions in small and large animals have improved markedly in the last 15 years, as management has improved, making the financial and emotional investment in critical care worthwhile for many owners.

References
[1] Dhupa N, editor. Critical care: cardiovascular focus. Vet Clin N Am Small Anim Pract 2001;31(6):1115 367.

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